Infection and Drug Resistance
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Shigella: Antibiotic-Resistance Mechanisms And
New Horizons For Treatment
Reza Ranjbar
Abbas Farahani
Molecular Biology Research Center,
Systems Biology and Poisonings Institute,
Baqiyatallah University of Medical
Sciences, Tehran, Iran
Correspondence: Reza Ranjbar
Molecular Biology Research Center,
Systems Biology and Poisonings Institute,
Baqiyatallah University of Medical
Sciences, Iran
Tel +98 21 8803 9883
Email Ranjbarre@gmail.com
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http://doi.org/10.2147/IDR.S219755
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This article was published in the following Dove Press journal:
Infection and Drug Resistance
Abstract: Shigella spp. are a common cause of diarrheal disease and have remained an
important pathogen responsible for increased rates of morbidity and mortality caused by
dysentery each year around the globe. Antibiotic treatment of Shigella infections plays an
essential role in reducing prevalence and death rates of the disease. However, treatment of
these infections remains a challenge, due to the global rise in broad-spectrum resistance to
many antibiotics. Drug resistance in Shigella spp. can result from many mechanisms, such as
decrease in cellular permeability, extrusion of drugs by active efflux pumps, and overexpres-
sion of drug-modifying and -inactivating enzymes or target modification by mutation.
Therefore, there is an increasing need for identification and evolution of alternative ther-
apeutic strategies presenting innovative avenues against Shigella infections, as well as paying
further attention to this infection. The current review focuses on various antibiotic-resistance
mechanisms of Shigella spp. with a particular emphasis on epidemiology and new mechan-
isms of resistance and their acquisition, and also discusses the status of novel strategies for
treatment of Shigella infection and vaccine candidates currently under evaluation in pre-
clinical or clinical phases.
Keywords: Shigella, antibiotics, resistance, drug resistance, mechanism, treatment, biofilm,
efflux pumps, prevention, vaccine
Introduction
Shigella spp. are a Gram-negative, rod-shaped, immotile, and non-spore–forming
bacteria and a causative agent of acute diarrhea that may progress to bloody mucoid
diarrhea, also known as bacillary dysentery (or shigellosis).1 Shigella is the most
common cause of diarrheal disease and has remained a major pathogen responsible
for increased rates of morbidity and mortality caused by dysentery each year around
the globe, particularly affecting children aged <5 years in developing countries.2
The four types of Shigella spp. comprise subgroup A (S. dysenteriae), subgroup B
(S. flexneri), subgroup C (S. boydii), and subgroup D (S. sonnei). Each subgroup
contains several serotypes. Shigellosis can occur in pandemic, epidemic, and
sporadic forms. Epidemiological reports have shown that the epidemic subgroup
of diarrhea typically occurs as a result of infection with S. flexneri in developing
countries and S. sonnei in industrialized countries.1,3 Shigella spp. are categorized
by the World Health Organization (WHO) as bacteria mainly causing infections in
the community.4 Shigellosis is a great public health threat, because its infective
dose is on the order of 10–100 organisms compared to other enteric pathogens
(usually it is 105–108 for Salmonella and Vibrio, respectively).5,6
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Antibiotic treatment of common bacterial infections
plays an important role in reducing prevalence and death
rates of the disease. However, incorrect antibiotic use or
overuse in treating diarrhea increases antibiotic resis-
tance. Shigella spp. are resistant to most antibiotics,
and drug treatment related to these bacteria is costly,
time-consuming, and sometimes problematic, particu-
larly in areas with limited medical care.7,8 About half
the strains of Shigella in many parts of the world are
now resistant to multiple drugs. Recently, various anti-
biotic-resistance mechanisms have been described by
researchers, and these antibiotic-resistance mechanisms
limit therapeutic options for treatment of Shigella
infections.8,9
Drug resistance in Shigella spp. can result from many
mechanisms, such as extrusion of drugs by active efflux
pumps, decrease in cellular permeability, and overexpression
of drug-modifying and -inactivating enzymes or target mod-
ification by mutation.6,10,11 The current study was done to
review various antibiotic-resistance mechanisms of Shigella
spp., with a particular focus on epidemiology and new
mechanisms of resistance and their acquisition, and also to
discuss treatment and prevention measures for diseases caused
by these organisms.
Search Strategy
We searched the biomedical electronic databases Web of
Science, Scopus, PubMed (Medline), Embase, Cochrane
Library, and Google Scholar for articles on Shigella
published in English between 1990 and May 2019,
using the key terms (alone and in combination)
“Shigella”, “drug resistance”, “mechanism”, “biofilm”,
“efflux pump”, “vaccine”, and “treatment”. We excluded
case reports and some studies on the implementation of
established techniques. Articles published before 1990
were also excluded, except when necessary. A total of
193 relevant articles were identified from the databases
and included in this review.
Drug-Resistance Mechanisms In
Shigella Spp
Role Of Outer-Membrane Permeability
Natural resistance to antimicrobial drugs by various
mechanisms preventing the drug from being absorbed
is capable of transforming the drug, its biotransforma-
tion into the cell, or reducing affinity with the drugs’
target.12 Cell walls of microorganisms are the first
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barrier against penetration of the drug. Some modifica-
tions of membrane permeability or changes in the
membrane lead to porin loss, which can result in an
increase in minimum inhibitory concentration(MIC) for
antimicrobial agents.13 Most antibiotics used in treat-
ment of Shigella infection should be able to penetrate
the cell membrane to reach intracellular accumulation
and target sites. For example, quinolone antibacterial
agents, such as nalidixic acid, ofloxacin, and ciproflox-
acin, interfere with DNA replication by inhibiting DNA
topoisomerase IV and gyrase. Aminoglycoside antibio-
tics, such as streptomycin and spectinomycin, mediate
inhibition of protein synthesis by binding to ribosomal
subunits and reaching intracellular targets. β-Lactam
antibiotics, eg, penicillin and cephalosporin, are a
class of antibiotics containing a β-lactam ring in their
molecular structures and inhibit cell-wall biosynthesis
by targeting penicillin-binding proteins. Mutation or
absence of ∼39 kDa porin in the membrane of such
Gram-negative bacteria as Shigella spp. mainly influ-
ences susceptibility to slow penetration of β-lactams,
such as aztreonam and dianionic moxalactam, and also
low permeability of hydrophilic antibiotics, such as
penicillin and piperacillin.6,13 Indeed, resistance toward
β-lactam antibiotics is associated with modification of
the outer-membrane porins OmpF (∼38 kDa) and
OmpC (∼42 kDa) and cytosolic proteins of ∼26 kDa,
OmpR as a transcriptional regulator.6 In a study, three
imipenem-resistant mutants of S. dysenteriae were
obtained from India and showed lower levels of both
major OMPs (∼38 and ∼43 kDa). Increasing imipenem
resistance in mutants was associated with permeability
of outer-membrane proteins.14 Lipopolysaccharides
(LPSs) have been recognized as an essential outer-
membrane component needed for assembly of trimeric
PhoE porin and confer colicin E2 resistance in S. flex-
neri strains,15 and have also been reported to be linked
with the rise in resistance toward imipenem in S.
dysenteriae.14 Some outer-membrane components,
such as IcsA molecules, are not only associated with
bile salts resistance but are also related to promotion
in development of biofilm by mediating bacterial cell–
cell interactions. Consequently, they produce resistant
phenotypes.16
Efflux Systems
Active efflux pumps play a significant role in antibiotic-
resistance phenotypes of Gram-negative bacteria and
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expelling toxic compounds from their cells. Efflux systems
are grouped into five families: the major facilitator super-
family (MFS), resistance–nodulation–division family, small
multidrug resistance (MDR) family, ATP-binding cassette
superfamily, and multidrug and toxic compound extrusion
family.17 AcrAB–TolC pump is involved in antibiotic resis-
tance phenotype of Escherichia spp., Enterobacter spp.,
Salmonella spp., and Shigella spp isolates. The AcrAB–
TolC system is a tripartite complex comprising TolC (outer-
membrane channel), AcrB (inner-membrane transporter
protein), and periplasmic AcrA involved in assembly and
maintenance of these two integral membrane proteins.
AcrAB–TolC belongs to resistance–nodulation–division
family of efflux pumps, associated with efflux of quinolones,
and one of factors responsible for development of resistance
among Shigella isolates. Indeed, overexpression of AcrAB–
TolC results in overall decreased accumulation of quinolones
inside bacterial cells, also resulting in reduced susceptibility
to them.18 AcrAB-associated to bile-salt resistance has been
found in some strains of S. flexneri. Their expression has
been shown to increase after exposure to bile salts, and
enabled Shigella to resist bactericidal effects of bile.
Researchers believe that this phenomenon may confer resis-
tance to other antimicrobial agents. Furthermore, overexpres-
sion of AcrB has been found to be linked to multiple drug-
resistance phenotypes in some Gram-negative bacteria.19
Synergistic action regarding activation of acrAB–tolC
efflux pumps has been shown to decrease expression of
outer-membrane porins, gyrase, and topoisomerase target–
gene mutations toward fluoroquinolone resistance in Shigella
isolates.20,21 Drug-efflux pumps, such as marA, tolC, ydhE,
and mdfA, confer quinolone resistance. Kim et al demonstrated
that resistance to fluoroquinolone is due to increased expres-
sion level of MdfA efflux pump in Shigella spp. This efflux is a
member of the MFS antibiotic-efflux system, and MdfA efflux
pump–mediated fluoroquinolone resistance was first identified
among MDR Escherichia coli.22 Tetracycline efflux and resis-
tance is associated with the MFS antibiotic–efflux system
encoded by various tet genes in Gram-negative bacteria, such
as Shigella spp. and Klebsiella spp. Among tet efflux systems,
it seems that tetA and tetB are mediated by resistance to
tetracycline in S. sonnei and S. flexneri, respectively (for
more details, refer to “Tetracycline Resistance” section).11
Resistance To β-Lactam Antibiotics
Class A β-Lactamases
Class A β-lactamases can hydrolyze narrow-spectrum peni-
cillin, but not carbapenems or cephalosporins, and are
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inhibited by tazobactam and clavulanic acid. Extended-spec-
trum β-lactamases (ESBLs) belong to Ambler class A.
ESBLs conferring resistance to third-generation cephalos-
porins have been found in Shigella isolates. The first report
documenting identification of ESBL-producing Shigella
strains was from Bangladesh in 2004.23 Emergence of
ESBLs in Shigella spp. is a global major health threat affect-
ing both developed and developing countries. Different β-
lactamases belonging to Ambler class A have been reported
among Shigella isolates, such as TEM, SHV, and CTX-M
enzymes. The first isolate of S. flexneri producing an ESBL
and harboring a plasmid encoding the blaSHV-2 gene was
reported from France in 1995.24
To date, several reports from Argentina, Israel, Canada,
Turkey, Lebanon, Japan, Iran, South Korea, China, and other
various regions in Asia have identified Shigella spp. harboring
different types of ESBL genes (Table 1).23,25–32 Although
most ESBLs are derivatives of TEM and SHV β-lactamase
families, which were first identified, Shigella spp. can also
express the CTX-M family, among which CTX-M-15 is one
of the most relevant findings associated with the current epi-
demiology of ESBLs, which has been predominantly identi-
fied in commensal and pathogenic ESBL-producing Shigella
isolates around the world. Despite many surveillance studies
and investigations, the reason for this epidemiological shift
remains unknown.24,33 These enzymes are responsible for
selective hydrolysis of ceftriaxone and cefotaxime and even
more distinctly for ceftazidime, although some types of CTX-
M, such as CTX-M-15, may hydrolyze ceftazidime.33 In gen-
eral, CTX-M-15 has been found to have great catalytic effi-
ciency (high kcat/Km) against piperacillin, benzylpenicillin,
ceftriaxone, and cefotaxime, as reported for other of CTX-
M-types, such as CTX-M-3, CTX-M-16, and CTX-M-18.
To date, CTX-M-15 has been detected in Shigella iso-
lates from various countries across the world, including
Canada, Russia, Poland, the UK, France, Bulgaria, Turkey,
and Iran.33,34 CTX-M-type β-lactamases contain at least
40 enzymes, and these can be readily transferred among
Shigella isolates by conjugative plasmids belonging to
IncF, IncZ, and Incl groups.34,35 Li et al revealed that
ISEcp1 was present adjacently to all blaCTX-M genes in
Shigella strains, meaning that it plays an important role in
mobilizing blaCTX-M genes (Figure 1).36 A large study
conducted in Vietnam analyzed IncI1 plasmid pKHSB1
carrying blaCTX-M-15 collected from a clonal population
of S. sonnei.37 Another study reported full sequence of
IncI1 plasmid pSH4469 carrying blaCTX-M-15 in a clinical
isolate of S. sonnei isolated from an outbreak in South
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Table 1 Prevalence Of Antimicrobial Resistance Genes In Shigella Spp. Isolated From Different Regions Of The World
Antimicrobial Resistance Genes Origin Geographic Origin Reference
Class Mechanism Mediating
Antimicrobial
Resistance

β-Lactams Class A β-lactamases blaSHV-2 P Argentina, France 32

191
blaSHV-11 C, P India
40
blaSHV-12 P China, Turkey

blaPER-2 — Argentina 32

25,26,31,40,120,192
blaTEM-1 I, P Lebanon, Chile, China, India, Iran, US,
Djibouti, Denmark, France, Greece, Brazil,
South Korea, UK, Romania
34,40
blaTEM-1b I, P China, South Korea

blaTEM-15 – South Korea 28

28
blaTEM-17 South Korea

blaTEM-19 – South Korea 28

blaTEM-20 – South Korea 28

28
blaTEM-52 P South Korea
40
blaCTX-M-1 P China
30,32,39
blaCTX-M-2 P Argentina, Turkey, South Korea, Israel
30,39,40
blaCTX-M-3 P China, Turkey, Argentina, South Korea, India,
Israel
39,40,193
blaCTX-M-14 P China, Turkey, Argentina, South Korea, US,
Japan
26,31,33,34,40,194
blaCTX-M-15 C, P China, Spain, Iran, South Korea, India, US,
Lebanon, Japan, Poland, New Zealand,
France, Romania
51
blaCTX-M-22 P China
40
blaCTX-M-24 P China
40
blaCTX-M-27 P China

blaCTX-M-28 – China 36,51

blaCTX-M-39 – Israel 30

35,40
blaCTX-M-55 P China, South Korea

blaCTX-M-57 – China 51

195
blaCTX-M-64 P Japan
192
blaCTX-M-65 P China
40
blaCTX-M-79 P China
40
blaCTX-M-123 P China

(Continued)

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Table 1 (Continued).

Antimicrobial Resistance Genes Origin Geographic Origin Reference

Class Mechanism Mediating
Antimicrobial
Resistance

Class B β-lactamases blaIMP-like P India, France 43,46

blaKPC – Senegal, France 46

44
blaIMP-3 P Japan

blaVIM-like – India 43

Class C β-lactamases blaCMY-2 C, P China, Mexico, India, Iran, Taiwan, Costa 48,51

Rica, Romania
31
blaCMY-59 C Iran
30,51
blaDHA-1 C, I, P China, India, Israel

Class D β-lactamases blaoxa-1-like I, P Mozambique, Chile, China, India, US, Egypt, 105,193,196

Djibouti, Spain, Greece, Denmark, Peru, Iran

30,105
blaoxa-2-like I Mozambique, Spain, Israel

blaoxa-5-like – Mozambique, Spain 105

51,91,120
blaoxa-30-like I, P Senegal, China, France, Japan, Spain, Brazil
50,75
Quinolones Plasmid-borne qnrA P Iran
resistance 64,65,75
qnrB P China, India, Iran
61
qnrB4 P Switzerland
61
qnrB19 P Switzerland
65
qnrC P India
53,66,75,94
qnrS P Iran, China, India, Pakistan
48,61,64
qnrS1 P Iran, China, Switzerland, US
50,64–66
aac-(60)-Ib-cr P US, India, Japan, China, Iran
61,64
Efflux pumps qepA P China, Switzerland
38
Fosfomycin Fosfomycin resistance fosA3 P China
enzymes
86,93,94,97,122
Aminoglycosides: strA MGE India, Australia, Chile, Pakistan, South Korea
streptomycin 86,94,97,122
strB MGE India, Chile, Pakistan, South Korea
83,86,88,91,94,97,98,120
Adenyltransferase aadA1 I, P Senegal, Bhutan, India, Taiwan, Spain, China,
Iran, France, Australia, Brazil, Pakistan,
South Korea
46,83,88,97,98
aadA2 I, P Taiwan, Spain, China, South Korea, France,
Australia, Korea
88,98
aadA5 I, P Taiwan, China, Iran

(Continued)

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Table 1 (Continued).

Antimicrobial Resistance Genes Origin Geographic Origin Reference

Class Mechanism Mediating
Antimicrobial
Resistance
11,88,94,97,104–106,120
Tetracycline Efflux pumps tetA C, P Mozambique, Taiwan, Chile, Peru, Brazil,
Iran, Spain, Pakistan, South Korea
11,46,88,94,104,106,120
tetB C, P Mozambique, Taiwan, Peru, France, Brazil,
Iran, Spain, Pakistan
104,105
tetG C, P Mozambique, Spain
46,83,86,88,91,98,105,122
Trimethoprim Dihydrofolate dfrA1 I, P Spain, Taiwan, Senegal, Mozambique, India,
reductases Bhutan, China, Iran, South Korea, Peru,
France, Chile, Australia
91,98
dfrA5 I, P Spain, Senegal, China
46,106
dfrA7 I, P Spain, Iran, France
105,122
dfrA8 P Mozambique, Chile
11,83,88,97
dfrA12 I, P Spain, Taiwan, Korea, Australia, South Korea
97
dfrA13 P South Korea
105,122
dfrA14 P Mozambique, Chile
105
dfrA14-like P Mozambique
91
dfrA15 I, P Spain, Senegal
91
dfrA16 P Spain
88,98,106,120
dfrA17 I, P Taiwan, China, Iran, Brazil
98
dfrV I, P China, India
83,88,97
Sulfonamides Plasmid-borne sul1 I, P Australia, South Korea, Taiwan
resistance 86,88,97,122,126
Sul2 I, P Taiwan, India, Peru, Chile, Bangladesh, South
Korea
88
Sul3 I, P Taiwan
46,86,88,94,120
Phenicols Chloramphenicol CatA-like P Taiwan, Mozambique, India, Peru, France,
acetyltransferase Brazil, Pakistan
genes 94
catP P Pakistan
88,105
Efflux pumps cmlA1 I, P Taiwan, Mozambique
112,116
Colistin Plasmid-borne mcr-1 P China, Vietnam
resistance
61,116,127,128,133
Macrolide Enzymatic inactivation mphA P Palestine, Switzerland, Vietnam, China,
Canada, UK, Peru
128,133
rRNA methylase ermB P Vietnam, Canada, UK
Abbreviations: P, plasmid; C, chromosome; I, integron; —, unknown; MGE, mobile genetic element.

Korea.34 The overall structure of plasmid pSH4469 was responsible for dissemination of blaCTX-M-15 among
nearly identical to pKHSB1, and it seemed that both were Shigella isolates (Figure 1).

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Figure 1 Schematic representation of blaCTX-M-55, blaCTX-M-15, and blaTEM-1 genes in different types of plasmid. Arrows indicate positions and directions of different genes
and IRL, terminal inverted repeats at the left, IRR, terminal inverted repeats at the right.

was carried by two conjugative plasmids named IncHI2 and

Figure 2 Physical map of Shigella atypical class 1 integron and locations of blaOXA-30
and aadA genes.
Recently, a new hybrid of CTX-M-9 and CTX-M-1 β-
lactamases named CTX-M-123 was identified among S. flex-
neri isolates from patients in China. In this study, blaCTX-M-123
IncF, and these conjugatable plasmids were responsible for
dissemination of blaCTX-M-123 in S. flexneri isolates.38
Moreover, several new β-lactamase subtypes — CTX-M-79,
CTX-M-27, CTX-M-24, CTX-M-15, CTX-M-14, CTX-M-
64, CTX-M-65, CTX-M-55, and CTX-M-3 — have been
found in clinical Shigella strains isolated from different pro-
vinces in China.36,39,40 ESBL genes among Shigella isolates
might be transferred from E. coli isolates to Shigella spp.,
especially S. sonnei isolates, through conjugation in human

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gut.41,42 The increase in MDR and emergence of ESBL in
Shigella spp. may be the cause of treatment failures and
accordingly limitation in therapeutic options.41
Class B β-Lactamases
Class B β-lactamase enzyme can hydrolyze carbapenem
and other β-lactams, except for aztreonam, and classical β-
lactamase inhibitors, such as tazobactam and clavulanic
acid, do not inhibit them. Metallo-β-Lactamase was first
detected in a transferable plasmid from Pseudomonas aer-
uginosa, and also IMP-1 was first identified from many
kinds of Gram-negative rods in Japan.43,44 O’Hara et al
reported a novel type of metallo-β-lactamase named MET-
1 mediated by a S. flexneri plasmid. They believed that
MET-1 was a derivative of IMP-1 β-lactamase.44 This
plasmid conferred resistance against sulfonamide and
kanamycin, in addition to β-lactamase.44 Lyobe et al
found that MET-1 experienced two amino-acid changes
from IMP-1. The gene was renamed IMP-3, and thus
IMP-3 could be considered an ancestor of IMP-1 β-lacta-
mase. They also showed that this gene was located on a
cassette inserted in a class I integron, widely disseminated
among other species of Shigella, and conferred resistance
to almost all β-lactam antibiotics.45
Carbapenem resistance conferred by blaVIM and blaIMP
genes has recently been detected in S. sonnei and S. flexneri
isolates from pediatric patients with diarrhea in the
Andaman and Nicobar islands in India.43 In this study,
after analysis of nucleotide sequencing of blaIMP and blaVIM
genes by BLAST, 100% similarity with sequences of these
genes isolated from Acinetobacter baumannii and P. aeru-
ginosa available at the NCBI database was confirmed. After
spread of carbapenem resistance to Shigella in another part
of the world, an indication of a potential public health
challenge, treatment options will be limited, and infection-
control measures remain of high importance.43 Finally,
although class A β-lactamase KPC is one of the most
commonly identified carbapenemases among other Gram-
negative bacteria in some parts of the world, it has not yet
been identified in Shigella isolates, except for a single bla-
KPC-carrying S. flexneri strain isolated from the National
Senegalese Enterobacteriaceae Center located at the Pasteur
Institute in Dakar.46
Class C β-Lactamases
Ceftriaxone is recommended for treatment of ciprofloxacin-
resistant Shigella isolates. However, today some strains of
Shigella spp. have a resistance gene to cephalosporins. Class
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C β-lactamases, also known as AmpC-type enzymes, confer
high-level resistance against cephalosporins. AmpC β-lacta-
mase is encoded by both plasmid and chromosomal genes,
and the first report of plasmid-encoded CMY-2-type AmpC
β-lactamase was detected among ceftriaxone-resistant S. son-
nei isolates obtained from an outbreak of bacillary dysentery
in Taiwan.47 CMY-2 enzymes have been reported in China,
Taiwan, Costa Rica, Iran, and India from several epidemic
strains.47–50 Zhang et al found two AmpC β-lactamase pro-
ducers with blaCMY-2 and blaDHA-1 in Shigella strains recov-
ered from diarrhea patients in China.51
Tajbakhsh et al reported on the first AmpC β-lactamase
(blaCMY-2) producers in S. sonnei isolated from patients in
Tehran, Iran.48 In recent years, other studies conducted in
Iran have indicated spread of resistance to extended-spectrum
cephalosporins among Shigella isolates.31,50 In a similar study
carried out in Iran, studying cephalosporin-resistant Shigella
isolates, the researchers identified gene CMY-59 in one S.
sonnei isolate from pediatric patients aged <12 years.31
However, the majority of AmpC-positive isolates studied in
other parts of the world belonging to the CMY-2 genotype and
other AmpC genes (blaMOX, blaFOX, blaMIR(ACT-1), blaCIT, and
blaACC) have been identified in Shigella isolates; however, so
far there has not a study on them.52,53 Indeed, few reports have
described the presence of AmpC β-lactamases among Shigella
isolates worldwide (see Table 1 for more details).47,48
Class D β-Lactamases
Class D β-lactamases or OXA-type β-lactamases confer resis-
tance to ampicillin and cephalothin and can hydrolyze oxacil-
lin and cloxacillin, as well as benzylpenicillin, but they are not
inhibited by tazobactam or other inhibitors.52,54 Initially,
blaOXA β-lactamases were reported among P. aeruginosa iso-
lates, although now blaOXA genes have been identified in
integrons and plasmids in many Gram-negative bacteria.55 In
Shigella spp., resistance to ampicillin is mainly associated with
an OXA-type β-lactamase.54,56 blaOXA-30 was initially
described in ampicillin-resistant S. flexneri strains from
China in 2000.57 Results of some studies have shown that S.
flexneri isolates are a probable host specific for blaOXA-type β-
lactamase.52,58 Another study from Iran showed that all bla-
OXA-positive isolates carried blaOXA-1 and many of them were
present in S. flexneri, suggesting an individual host preference
of these enzymes in S. flexneri isolates.50
blaOXA-1 and blaOXA-30 genes, containing Tn2603 and
Tn1409 transposons, respectively, differ from each other by
having one mutation at codon 131. A gene encoding
blaOXAβ-lactamases is carried on integron.58 Furthermore,
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other studies have shown that blaOXA-30 and aadA1 are
located in the gene cassettes of class 1 integrons (Figure 2).
Therefore, class 1 integrons carry resistance traits for β-
lactams (blaOXA) and trimethoprim (dfrA1).52
Quinolone And Fluoroquinolone
Resistance
Resistance To (Fluoro)quinolones Due To
Chromosomal Target–Site Mutations
Corresponding subunits for DNA gyrase and topoisomerase
IV are gyrA, gyrB, parC, and parE, encoded by genes gyrA,
gyrB, parC, and parE genes, respectively. DNA gyrase
consists of two gyrA subunits and two gyrB subunits, and
topoisomerase IV contains two parC and two parE subu-
nits. The most mutations have been found in a small region
near the start of the gyrA gene termed a quinolone resis-
tance–determining region (QRDR), between Ala67 and
Gln107, and as reported in several studies (Table 2), most
frequently mutations occur at codons 83, 87, and 211, while
mutations in gyrB were detected with lower frequencies in
different studies.59,60 Some researchers believe that when a
single mutation occurs in gyrA, it may confer resistance to
quinolones, but for decreased susceptibility to fluoroquino-
lones, a number of further mutations in parC and gyrA
regions are needed.61,62 parC gene mutations most fre-
quently occur at codons 80 among Shigella isolates. gyrA
gene mutations have been confirmed to be much more
prevalent than mutations in the gyrB gene.63,64 Most
nucleotide and amino-acid changes in QRDRs of gyrA,
gyrB, parC, and parE among Shigella spp. are shown in
Table 2. Novel mutations in QRDRs have also been identi-
fied from different regions of the world. Two novel muta-
tions at codons 86 and 129 in parC and a mutation in codon
211 of gyrA were first reported in S. sonnei strains recovered
from China in 2009.65
Finally, two novel mutations at codons 408 and 458 in
parE have recently been discovered among Shigellaspp.,
isolated in India in 2013 and Jiangsu Province in China in
2016.10,63 Mutation in codon 458 is believed to result in
resistance to ciprofloxacin and nalidixic acid, while a
single isolate with a mutation at codon 408 in parE is
related to resistance to nalidixic acid, but susceptible to
ciprofloxacin. It seems that both the novel mutations in
parE of S. flexneri isolates may be correlated with the
increased MIC for ciprofloxacin and mediate fluoroquino-
lone resistance. Also, in neither study were parE mutations
identified among quinolone-sensitive isolates.10,63
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Data presented in Table 2 show that mutation patterns
in gyrA and parC genes, particularly common mutations,
are similar to those reported by other studies, reflecting a
universal pattern among Shigella spp. A direct contribu-
tion to quinolone and fluoroquinolone resistance by each
of these mutations in chromosomal target–site mutations
(QRDRs) remains unknown. However, other mechanisms
may be present in Shigella isolates, and further investiga-
tions are needed.
Resistance To (Fluoro)quinolones Due To Plasmid-
Mediated Resistance Mechanisms
Distribution of plasmid genes called plasmid-mediated qui-
nolone-resistance regions (PMQRs) namely qnr (qnrA,
qnrB, qnrC, qnrD, qnrS, qep, aac[6ʹ]-lb-cr) genes is the
main reason for resistance to quinolones among Shigella
isolates, and they are usually associated with transposable
or mobile elements on plasmids.64,66 qnr genes, which are
often incorporated into integrons, may allow for dissemina-
tion among Shigella and possibly other members of the
Enterobacteriaceae family, and then quinolone-resistance
isolates may spread across geographic regions and even
across countries with population mobility.65,67 The aac(6′)-
Ib-cr gene encodes an acetyltransferase associated with
reduced quinolone activity, and is identified in many mem-
bers of the Enterobacteriaceae family.68 PMQRs have been
identified widely among human and animal isolates, and
have become a pressing issue worldwide. In a study con-
ducted in China, fluoroquinolone-resistance rates in animal
isolates of S. flexneri were reported to be higher than those
in human strains.68
In the US, the Shigella resistance rate to fluoroquinolones
reached 87% during 2014–2015.69 Resistance of Shigella
isolates to fluoroquinolone is mainly due to mutational altera-
tions in QRDRs of DNA gyrase and topoisomerase IV genes,
but PMQRs may facilitate in selection of isolates exhibiting
higher levels of resistance through extrachromosomally
encoded mechanisms and confer reduced susceptibility to
quinolones (or fluoroquinolones).68 aac(6′)-Ib-cr and qnrS
genes were first identified in isolates of S. flexneri 2a in 1998
and S. flexneri serotype 1a in 2002, respectively.70,71
Furthermore, the qnrS gene was identified in isolates of
Shigella flexneri 2b in 2005 in Japan.70 Also, as reported in
two previous studies, aac(6′)-Ib-cr and qnrS were predomi-
nant PMQR determinants across two provinces in China,
conferring high levels of fluoroquinolone resistance.72,73
These studies indicated that aac(6′)-Ib-cr–positive Shigella
isolates have been present in China for many years.70,72,73
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Table 2 Frequency Of Amino-Acid And Nucleotide Changes In The Quinolone Resistance–Determining Regions Of ShigellaIsolates In
Different Parts Of The World
Target Codon Amino- Nucleotide Shigella spp. Country Of Detection Reference(s)
Site Acid Mutation
Mutations Changes

gyrA 57 Asn→Lys AAT→AAA S. flexneri China 197

69 Gln→Trp — S. sonnei India 65

71 Phe→Ser — S. sonnei India 65

72 Ser→Pro — S. sonnei India 65

75 Met→Leu — S. sonnei India 65

80 His→Pro CAT→CCT S. flexneri China 197

197
80 His→ Gly CAT→GGT S. dysenteriae Belgium

83 Ser→Leu TCG →TTG S. sonnei, S. flexneri, S. dysenteriae, China, Bangladesh, Switzerland, 21,58,61,64

S. boydii Thailand, India

87 Asp→Asn GAC→AAC S. sonnei, S. flexneri, S. dysenteriae China, Bangladesh, Switzerland, 21,52,64

India

87 Asp→Gly GAC→GGC S. sonnei, S. flexneri, S. dysenteriae China, Switzerland, Thailand, India 21,61,64

87 Asp→Tyr GAC→TAC S. sonnei, S. flexneri Switzerland 61

90 Ser→Cys — S. sonnei India 65

94 Met→Leu — S. sonnei India 65

106 His→Pro — S. sonnei India 65

161 Asn→His — S. sonnei India 65

163 Thr→Ala — S. sonnei India 65

196 Val→Ala — S. flexneri, S. dysenteriae India 21

211 His→Tyr CAC→TAC S. sonnei, S. flexneri China, Bangladesh 8,62,64

gyrB 517 Gln→Arg CAG→CGA S. flexneri China 62,71

parC 64 Ala→Asp GCC→GAC S. sonnei, S. flexneri, India, China 65

65
64 Ala→Cys GCC→TGC S. sonnei China

80 Ser→Ile AGC→ATC S. sonnei, S. flexneri, S. dysenteriae, China, Bangladesh, Switzerland, 21,40,57,61,62,64

India

81 Ala→Pho — S. flexneri China 71

83 Ser→Leu — S. flexneri China 30

85 Ala→Thr GCG→ACG S. flexneri China 71

61
85 Ala→Ser GCG→TCG S. boydii Switzerland
64
86 Met→Trp ATG→TGG S. sonnei China

91 Gln→His — S. flexneri China 71

93 Phe→Val — S. flexneri, S. dysenteriae India 21

101 Asp→Glu — S. flexneri, S. dysenteriae, India 21

(Continued)

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Table 2 (Continued).

Target Codon Amino- Nucleotide Shigella spp. Country Of Detection Reference(s)

Site Acid Mutation
Mutations Changes

110 Asp→Glu — S. flexneri, S. dysenteriae India 21

111 Asp→His GAT→CAT S. flexneri China 62,64

62,64
129 Ser→Pro TCC→CCC S. sonnei China

parE 408 Gly→Asp GGC→GAC S. flexneri China 62

458 Ser→Leu TCG→TTG S. sonnei, S. flexneri, S. dysenteriae China, India 62

458 Ser→Ala TCG→GCG S. sonnei, S. flexneri, S. dysenteriae India 62

Note: —, unknown.

S. flexneri serotypes 1a, 2a, 2b, 4c, and S. sonnei carrying the
qnrS gene have been reported worldwide.67
Importantly, qnrS-positive isolates of Shigella, especially
S. flexneri strains, show high-level resistance to fluoroquino-
lones, and many researchers from different part ofs the world
suggest that the plasmid-mediated quinolone-resistance gene
qnrS plays an essential role in reduced susceptibility of
Shigella strains to fluoroquinolones.67,72,73 Indeed, qnrS plas-
mid could change fluoroquinolone susceptibility of S. flexneri
isolates containing both gyrA83 and parC80 mutations into
ciprofloxacin-resistant isolates.74 Overall, aac(6ʹ)-Ib-cr is the
most prevalent gene, followed by qnrS detected in isolates of
S. flexneri from the US, India, Japan, China, and Iran, and also
most studies have highlighted an increased prevalence of
PMQR determinants through the years.50,70,75–77 A recent
study conducted in China reported that aac(6)-Ib-cr–positive
isolates and qepA-positive isolates expressed high levels of
quinolone resistance. This finding indicates that other mechan-
isms, such as reduced outer-membrane permeability, active
efflux pumps, and harboring of different resistance genes,
may be responsible for resistance to quinolones.18,77
Fosfomycin Resistance
Fosfomycin (Fom) is a broad-spectrum antibiotic inhibiting
bacterial cell-wall biogenesis by inactivating the MurA
enzyme.38,78 Despite the use of Fom in treatment of micro-
bial infections for four decades, Fom has remained effective
against common uropathogens, and Fom resistance has
remained rare throughout the world.79 However, Fom resis-
tance was observed among E. coli strains to harbor novel
transferable fosfomycin-resistance determinants named
FosC2 and FosA3.80 Two primary resistance mechanisms
have been described for fosfomycin resistance: mutations in
uhpA/T and glpT genes encoding proteins for two carrier-
dependent systems responsible for fosfomycin uptake, and
attainment of fosfomycin-modifying enzymes containing
two kinases, FomA and FomB, and three types of metal-
loenzymes: FosX, FosA, and FosB.81
Fosfomycin-modifying enzymes were discovered for the
first time among S. flexneri strains isolated from patients in
China.38 Some studies have suggested that increasing pre-
valence of fosA3 was due to dissemination of IncN and IncI
plasmids, facilitating its quick dispersal.38,80 Indeed, ESBL
(blaCTX-M-123, blaCTX-M-55, or blaCTX-M-15) and fosA3 genes
were cocarried by transconjugant plasmids from diverse
incompatibility groups, and all of them contained determi-
nants encoding resistance to cefotaxime, ceftriaxone, and
fosfomycin.38,80 In this regard, conjugatable plasmids are
likely to play an essential role in dissemination of fosA3 and
ESBL genes among Shigella isolates with high clonal diver-
sity, and they should be closely monitored.38
Aminoglycoside Resistance
Aminoglycosides are used to treat a wide range of infec-
tions. Aminoglycosides mediate inhibition of protein
synthesis.82 Resistance to aminoglycosides is associated
with enzymatic inactivation, ribosomal modification, and
active efflux pumps. Among these mechanisms, aminogly-
coside-modifying enzymes are the most common in the
clinical setting.83–85 These enzymes are activated through
three general reactions, resulting in adenylation, acetyla-
tion, or phosphorylation. Aminoglycoside adenyltransfer-
ase (aadA gene cassettes) are very common in
Enterobacteriaceae, especially among Salmonella and
Shigella isolates, conferring resistance to streptomycin
and spectinomycin.84,86 Indeed, streptomycin resistance is

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strongly associated with integrons because of the high
prevalence of aadA gene cassettes within class 1 and 2
integrons. A typical class 2 integron has a gene cassette of
2.2 kb with a resistance-gene arrangement (dfrA1–sat–
aadA1) conferring resistance to trimethoprim, streptothri-
cin, and spectinomycin/streptomycin, respectively, while
aadA1 was absent in atypical class 2 integrons.87,88 Class
2 integrons have been identified in transposon Tn7 and
predominantly inserted into chromosomes with high
frequency.89 An atypical class 1 integron with an unusual
3ʹ conserved sequence carrying a estX–psp–aadA2–cmlA-
aadA1–qacH cassette array has been detected among dif-
ferent Gram-negative species (E. coli, Shigella, and
Salmonella) from different hosts (human, animal, and
food), periods and geographical regions. Accordingly, hor-
izontal transfer of these integrons by plasmids promotes
spread of multiple-resistance genes in sporadic and out-
break isolates of Shigella.89–91
Many types of aadA gene cassettes have been identified
among Enterobacteriaceae, but types aadA1 and aadA2
have high prevalence among Shigella isolates.84,89,92
Aminoglycoside phosphotransferases encoded by strA and
strB are the most common genes dispersed among Shigella
isolates by plasmids, such as IncFII and pNV-Y394.83,87,93,94
The gene encoding strA has been identified in 42.1% of
Shigella isolates recovered from diarrheal patients in
Pakistan.95 In a study conducted in India, 100% and 88% of
S. dysenteriae type 1 and S. sonnei strains harbored strA genes,
encoding resistance to streptomycin.96 The majority of
Shigella isolates harbored strA and strB, along with unrelated
resistance determinants, which are coded by blaTEM, blaCTX-
95,96
M, qnrS, aadA1, tet(A), tet(B), catA, and catP. A 6.3 kb
plasmid has been detected in the S. flexneri 3a strain and is
involved in a streptomycin-resistance phenotype. This plasmid
is likely to cause acquired resistance to streptomycin.97 Also, a
study conducted in South Korea showed that resistance to
streptomycin was mediated by strA or strB among S. sonnei
isolates obtained there and revealed that tetA, strA–strB, and
sul1 were encoded and present in 8.4 kb of untransferable R
plasmid.98
Occurrence of aminoglycoside-resistance genes among
Shigella isolates does not occur, because these drugs have
long been excluded for treatment of shigellosis in different
geographical areas.85 However, there is still a concern,
because class 1 integrons containing the gene-cassette
array of blaOXA-30 + aadA1 with complete 3′CS have
been reported on plasmids in Shigella spp. isolates,
Salmonella enterica serovar Typhimurium and E. coli
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strains, and transferable plasmids may enhance spread of
resistance genes within integrin, establishing arole of plas-
mids in horizontal transfer of resistance genes.99
Tetracycline Resistance
Tetracyclines are used against a wide variety of diseases in
humans and animals.100 Tetracycline-resistant bacteria are
found in opportunistic pathogens and normal flora species.
According to the study by Roberts101 and nomenclature for
tetracycline resistance genes(https://faculty.washington.
edu/marilynr), five tetracycline-efflux genes — tet(A), tet
(B), tet(C), tet(D), and tet(G) — and one ribosomal pro-
tection protein encoded by tet(M) have been identified
among Shigella isolates, most of which are encoded in
transmittable elements, with extensive dissemination in
different groups of bacteria. In a study, a 20.4 kb genomic
island was identified encoding MDR genes, such as a wide
variety of tet genes flanked by transposases.102 This iden-
tical MDR cassette was first identified in S. flexneri ser-
otype 2a strain YSH6000 and was referred to as Shigella
resistance locus–pathogenicity island.103 Interestingly,
these MDR genes have recently been found in an E. coli
plasmid, pRSB225, with a similar arrangement.104 The
IncB/O/K/Z-type plasmid, termed p866, carrying resis-
tance genes tet(A) and tet(B) have been identified in S.
sonnei strains.105 These findings suggest that tet genes
might be dispersed among other species by horizontal
gene transfer.
Among 154 tetracycline-resistant isolates recovered as
confirmed causes of traveler’s diarrhea in Spain, 79.2%
(n=122) harbored at least tet(A) or tet(B). Combinations of
tet(A) + tet(B), tet(A) + tet(G), and tet(B) + tet(G) were
found in five, one, and seven isolates, respectively.106
Results of two studies revealed that tet(A) was more
frequent among S. sonnei strains, whereas tet(B) was
more frequent among S. flexneri strains.106,107 Also, S.
sonnei and S. flexneri differed from each other in terms
of prevalence of plasmid Inc groups.106 In 50 isolates of
Shigella spp. identified from stool samples collected from
children with diarrhea in Iran, 90% and 18% of isolates
carried tetA and tetB, respectively, and no positive results
were identified for tet(C) or tet(D) in this study.11 Results
of the same study conducted in Iran revealed that tet(A)
and tet(B) were present in 75.7% and 21.42% of Shigella
spp. and that tet(A) was more frequent in S. flexneri and S.
sonnei populations.108
A study carried out in Mexico identified genes tet(A),
tet(B), and tet(C) in 1, 6, and 18 S. sonnei isolates, and 2,
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7, and 1 S. flexneri isolates, respectively, whereas tet(D)
was observed only in S. sonnei isolates (8%).109 Among
20 S. dysenteriae isolates from dysentery outbreaks
obtained from different parts of India, tet(B) was more
common (90%) than tet(A) (10%). In the same study,
genes tet(A) and tet(B) were detected in 15% and 79%
of Shigella isolates, respectively, samples of which were
obtained from children with diarrhea in southern
Mozambique.107 Based on recent studies,107,108,110 it
seems that efflux-mediated tetracycline resistance to tetra-
cycline in S. sonnei and S. flexneri strains may be related
to expression of tet(A) and tet(B), respectively. According
to tetracycline resistance–gene nomenclature (https://
faculty.washington.edu/marilynr), tet(B) is able to confer
resistance to minocycline, while other efflux pumps
encoded in a transferable tet gene do not have such a
property and may cause clonal dissemination of tet(B)-
positive Shigella isolates worldwide. In general, tet(A)
and tet(B) are the most prevalent tetracycline-resistance
genes in Shigella spp. Other tetracycline-efflux genes,
such as tet(C) or tet(D), are rarely detected alone.
Phenicol Resistance
Phenicols have used to treat Shigella infections during the
past few years around the world, and application of them
led to strong selective pressure for resistance to these
antibiotics.111 Resistance in Shigella is associated with
enzymatic inactivation of unfluorinated phenicols by chlor-
amphenicol acetyltransferase genes encoded by variants of
catA (catA1, catA2, catA3) and catB (catB2, catB3, catB7,
catB8), as well as active efflux by cmlA (cmlA1, cmlA4,
cmlA9) and/or fluorinated and unfluorinated phenicols (floR)
by major facilitator–superfamily proteins.112
Chloramphenicol resistance in Shigella isolates is
mainly associated with the presence of cat genes.
Among 95 Shigella isolates collected from diarrheal
patients in Pakistan, at least 69 (72.6%) were resistant
to chloramphenicol. catA and catP were detected in 32
(33.68%) and 24 (25.26%) isolates, respectively, from
chloramphenicol-resistant Shigella isolates.95 Among
103 S. sonnei isolates associated with several water-
borne outbreaks in Taiwan, in 84% of sporadic isolates,
tetB and catA genes were transferred along with 130 kb
plasmids.89 The presence of catA encoding chloramphe-
nicol O-acetyltransferase was detected and confirmed in
S. flexneri strains with strA or aadA1 genes or both.96
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Colistin Resistance
Colistin (polymyxin E) is a polypeptide antimicrobial agent
interacting with outer membranes of Gram-negative bacteria.
Since the first report of the plasmid-mediated polymyxin-
resistance gene mcr-1 was published in an E. coli isolate in
November 2016 in China,113 this gene has also been identified
in Salmonella enterica and Klebsiella pneumoniae, but is
rarely reported in other Enterobacteriaceae members here.114
This gene has now been identified in other Enterobacteriaceae
genera, such as Shigella, Cronobacter, Kluyvera, and
Enterobacter isolated from vegetables, the environment,
food, animals, and human beings.115,116 The mechanism of
resistance of mcr-1 is produced by a phosphatidylethanola-
mine transferase, leading to modification of lipid A present as
a result of addition of phosphoethanolamine to lipid A in cell
membranes of Gram-negative bacteria, resulting in more
cationic LPSs and lower affinity for colistin and related poly-
myxins and consequently reduced antimicrobial activity.117
The presence of mcr-1 in Shigella isolates leads to a four- to
eightfold increase in the MIC of polymyxin B.118 mcr-1 is
located on various plasmid backbones, including IncI2, IncFI,
IncHI2, IncFIB, IncP, IncY, and IncX4, sized 58–252 kb
(Figure 3).114 ESBL-encoding genes or other resistance
genes might coexist with it. Also, plasmid-mediated colistin-
resistant S. flexneri isolates recovered from animal feces on a
farm showed that it might be circulated via the fecal–oral
route, at least between animals on that farm, and possibly
distributed via the food-production network.118 In most
reports, mcr-1 is known to be the only resistance gene for
related plasmids, indicating that selective pressure associated
with polymyxin is responsible for mcr-1 acquisition.114,118 It
means that other plasmids conferring MDR phenotypes can be
achieved from resistant S. flexneri strains. Mobile elements,
such as IS and integrons, could also help isolates acquiring
other resistance elements from the environment.118 A novel
transposon, Tn6390 has been detected in S. flexneri C960, in
which two copies of ISApl1 bracketed to the mcr-1 gene play a
pivotal role in transposition of mcr-1.118 Recently, mcr-1 was
identified in S. sonnei isolates from Shanghai (2010–2012)
with polymyxin B resistance (MIC 4–8 μg/mL).118
Sulfonamide And Trimethoprim
Resistance
After the spread of trimethoprim–sulfonamide resistance in
different parts of the world, these agents are currently consid-
ered ineffective for empirical therapy of shigellosis.119
Acquired resistance mechanisms have frequently been
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Figure 3 Structure of genes surrounding mcr-1 in S. flexneri.
identified, mostly due to mutational or recombinational
changes in target enzymes (dihydropteroate synthase and dihy-
drofolate reductase, respectively) or acquired resistance by
drug-resistant target enzymes, such as acquired sul genes cod-
ing for drug-resistant dihydropteroate synthases or dfr genes
coding for drug-resistant dihydrofolate reductases.120,121
Resistance To Trimethoprim
At least 42 dfr genes conferring trimethoprim resistance
have been detected in different groups of bacteria world-
wide, 12 of which have been identified in Shigella spp.
Resistance to trimethoprim might be explained by the
presence of integron-borne dfr genes (Figure 4). Gene
cassettes within class 1 integrons detected on plasmids or
chromosomes in Shigella isolates often encode resistance
to trimethoprim (dfrA), streptomycin (aadA), and ampicil-
lin (oxa-1).58,85 Class 2 integrons borne on Tn7 have often
been found in Shigella spp., and gene-cassette arrays of
them usually contain dfrA1, sat1, and aadA1.122
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The presence of dfrA1 genes among Shigella isolates is
the main mechanism of trimethoprim resistance, occurring in
a cassette in both class 1 and class 2 integrons (Figure 4).
Two types of class 2 integrons among S. sonnei strains have
been identified in Japan. One of them was typical type of
class 2 integrons (2,158 bp) with dfrA1, sat1, and aadA1
cassette arrays, and the other was an atypical type of class 2
integrons (1,313 bp) carried only two gene-cassette arrays
with dfrA1 and sat1.123 This integron-associated antibiotic
resistance can be transferred to other species via plasmid
conjugation. dfr12–orfF–aadA2, dfr17–aadA5, and aadA1
cassette arrays carried by class 1 integrons have been recog-
nized in S. sonnei isolates recovered from South Korea,
China, Vietnam, and Australia.84,85,99 Also, dfrA1–sat1–
aadA1–orfX, free aadA1, or free orfX cassette arrays carried
by class 2 integrons have been detected in Senegalese
Shigella spp. isolates.92 In contrast to dfrA genes, dfrB
genes have not been identified among Shigella isolates.
Recently, trimethoprim-resistance clones were sequenced
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Figure 4 Variable regions of class 1 (A) and class 2 (B) integrons reported in different geographic area. Horizontal arrows indicate transcriptional orientation of genes.
by primer walking, and a native 6,779 bp plasmid was
identified with presence of the dfrA14 gene in a sul2–strA’–
dfrA14–‘strA–strB gene arrangement in S. sonnei strains,
suggesting that dfrA14 was associated with a small noncon-
jugative plasmid.124 Class 2 integrons within a dfr1–sat2–
aadA1 cassette array were predominant in S. sonnei isolates
from outbreaks cases in Taiwan, while class 2 integrons were
absent in sporadic cases.89
A large study conducted in South Korea analyzed 122
S. sonnei isolates collected from stool samples in different
parts of the country from 1991 to 2000. Resistance to
trimethoprim was associated with dfrA1 and dfrA12.
dfrA1 was found as a gene cassette of Tn7 located in
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chromosomes, while dfrA12 was located in conjugative R
plasmids as a gene cassette of class 1 integrons. Tn7 was
not detected in S. sonnei isolates recovered from the
1980s, while in this study Tn7 was found in all S. sonnei
isolates. The authors proposed that S. sonnei isolates car-
rying Tn7 were responsible for outbreaks of shigellosis in
different parts of South Korea in the 2000s.98
Resistance To Sulfonamides
Since the first report of resistance to sulfonamides was
found in both S. sonnei and S. flexneri isolates recovered
from the early 1970s in South Korea,98,125 resistance to this
antibiotic has been identified in 94 % of S. sonnei strains
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from the 1980s and 100% of isolates from the 2000s and
2010s in different parts of the world.2,50,118 Sulfonamide
resistance is mediated by sul1, sul2, and sul3 genes, and
they are common in Shigella.89 The sul1 gene is highly
frequent among Shigella isolates, because it is part of the 3ʹ-
conserved sequence region of class 1 integrons. Also, sul3,
linked to an unusual 3ʹ-conserved segment, is associated
with class 1 integrons.89,126 According to one study, sul2 is
one of the three sulfonamide-resistance genes, and is
usually located on large transmissible plasmids or small
non-conjugative plasmids and was first detected on a
small nonconjugative plasmid of E. coli.90 Since then, this
gene has been found mostly on plasmids in Shigella isolates
from humans in South Korea,98 Taiwan,89 Australia,127 and
Bangladesh.128
Several studies have suggested that sul genes are linked
to other resistance genes. The sul1 gene is often identified
together with other antimicrobial-resistance genes located
on gene-cassette arrays in variable regions of class 1
integrons. Class 1 integrons differ from class 2 in their
excise gene cassettes, capacity to integrate, and presence
of sul1 in 3′ conserved region (3′CS). In Brazil, sul1
(sulfonamide-resistant) was identified in two (3%) MDR
Shigella samples, which were also positive for class 1
integrons.122 In previous studies on MDR S. sonnei iso-
lates obtained in South Korea, resistance to sulfamethox-
azole was mainly associated with sul1, located in 8.4 kb of
nonconjugative R plasmid.98
Antibiotic-resistance gene clusters containing strA, strB,
and sul2 are widespread among Gram-negative bacteria,
particularly in Shigella isolates.124 Iqbal et al128 found
sul1, sul2, sul3, integron 1, and integron 2 genes in all
MDR S. flexneri 2a strains, and also found that sul2 was
absent in all sulfamethoxazole-sensitive strains (n= 54),
while it was present in all sulfamethoxazole-resistant strains
(n=146). However, in this study, no change was observed in
expressions of sul1, sul3, integron 1, or integron 2 genes in
sulfamethoxazole-resistant and -sensitive S. flexneri 2a
strains. Interestingly, curing of this 4.3 MDa plasmid
resulted in loss of sul2 and susceptibility to sulfamethox-
azole in paired strains, suggesting involvement of sul2 and
this plasmid in resistance to sulfamethoxazole. In the same
study, 24 S. sonnei isolates were detected to carry an atypi-
cal class 1 integron associated with sul3. The estX–psp–
aadA2–cmlA1–aadA1–qacH cassette array of sul3-asso-
ciated class 1 integron has been found to encode an esterase,
a lipase, putative phosphoserine phosphatase/resistance to
streptomycin, chloramphenicol, and quaternary amines.23
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Macrolide Resistance
The American Academy of Pediatrics and the Infectious
Diseases Society of America have recommended azithromy-
cin as a medication for treatment of shigellosis in children,
and also the WHO introduced it as second-line treatment in
adults.129 The Centers for Disease Control and Prevention
has observed resistance to azithromycin in approximately 3%
of Shigella cases tested. Resistant outbreaks involving
Shigella spp. isolates with reduced susceptibility to azithro-
mycin (RSA) are more recent phenomena and continually
detected in Asia, North America, the US, Australia130,131 and
other geographic regions.132–134 According to updated
Clinical and Laboratory Standards Institute guidelines, if
MICmeasured by broth microdilution is ≤16 and ≤8 µg/
mL, then epidemiological cutoff values denote susceptibility
for S. sonnei and S. flexneri wild-type, and if MIC is ≥32 and
≥16 µg/mL, then susceptibility is confirmed for non–
wild-type, respectively.135 Recently, several reports have
suggested that resistance to azithromycin in Shigella spp.
isolates is associated with presence of mphA or ermB plas-
mid-mediated genes or by both genes.133,136 Macrolide resis-
tance is mediated by four main mechanisms: enzymatic
inactivation by phosphotransferases encoded by mph genes
or esterases encoded by ere determinants; target-site modifi-
cation by an rRNA methylase encoded by erm genes; punc-
tual mutations in rplV encoding L22 ribosomal protein, rplD
encoding L4 ribosomal protein, and rrlH (23S rRNA); and
drug-resistance mediated by efflux pumps, such as OmpA,
OmpW, mefA, and msrA.137,138 All macrolide-resistance
mechanisms can mediate resistance to azithromycin and
erythromycin. The mph(A) gene was first identified in an E.
coli isolate from Japan.139 Since then, this gene has
been recognized among Pseudomonas spp., Aeromonas
spp., Stenotrophomonas spp., Shigella spp., and other
enteropathogens.137 Dissemination and acquisition of
macrolide mphA resistance mechanisms in Shigella spp. has
been shown to be mainly due to spread of plasmids from E.
coli.140 All the discovered mphA-associated plasmids have
been identified in E. coli isolates, indicating their role as a
repository from which antimicrobial resistance to Shigella
spp. may appear.135 This phenomenon has been previously
been described in E. coli donating mphA to S. sonnei.141
Additionally, Shigella strains with RSA have been
found mostly in strains recovered from men who have
sex with men (MSM; 68.8% or higher) from the
Montreal region. In this study, complete sequence analysis
of six selected plasmids from different serotypes of S.
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flexneri and S. sonnei emphasized the role of IS26 in
dispersal of RSA.130 Also, in a study conducted in
Taiwan, a series of clonally related azithromycin insuscep-
tible Shigella spp. isolates was reported in relation to
MSM.136 Various gene-transfer systems (mobile genetic
element acquisitions) are involved in acquiring antibiotic-
resistance genes, such as transposons, integrons, and con-
jugative plasmids. The IS26–mphA–mrx–mphR (A)–
IS6100 gene cassette has been characterized in a clinical
strain of S. boydii carrying the p2246–CTXM plasmid.
Insertion sequences of IS6100 and IS26 have been found
in the neighborhood of mphA in an S. sonnei strain recov-
ered from France. Indeed, in addition to plasmid mobiliza-
tion, dissemination, and acquisition of RSA among
Shigella spp. and serotypes has also potentially occurred
through IS26 mobilization.130,137
IncFI and IncFII plasmids have been shown to carry
the azithromycin-resistance gene erm.135 The IncFI plas-
mid containing an ISCR3 insertion sequence surrounds
both ermC and ermB genes and carries a blaCTX-M-24
gene downstream of an ISEcp1 element. The IncFII plas-
mid carries ermB and ermC genes downstream of an IS6
transposase. Both plasmids share significant DNA homol-
ogy with other previously sequenced plasmids found in S.
sonnei and S. flexneri serotype 3a isolates associated with
development of the disease in MSM.135
Recently, a plasmid carrying azithromycin-resistance
genes, namely pKSR100 (conjugative R-plasmid) in S.
flexneri serotype 3a has been described to be involved in
intercontinental spread of RSA among MSM-associated
outbreak lineage.142 pKSR100-like plasmids have been
found to be predominantly related to MSM-associated out-
break lineage in Australia and elsewhere.131 There are a
considerable number of studies on the prevalence of RSA
among Shigella isolates throughout the world, particularly
in MSM, and demonstrated global dissemination of a
multi-resistant plasmid, highly associated with MSM,
which is present across different continents.131,142
Biofilm Formation–Mediated
Resistance
Recently, much attention has been given to biofilm formation
in bacteria, because microbial cells grown in biofilms are less
sensitive to antimicrobial agents and more resistant to envir-
onmental stress such as dehydration and oxidation. Microbial
infections caused by biofilm-associated Shigella spp. are
global health challenges.143 Biofilm formation is regulated
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by a multifactorial process, with cellular adherence, exopo-
lysaccharide secretion, and numerous gene regulations con-
trolling detachment of bacteria from mature biofilm, and is
mainly related to quorum sensing and social networking in
the microbial world.144,145 Ellafi et al investigated biofilm
formation by Shigella strains grown in different NaCl con-
centrations, and they showed that all the isolates produced
biofilm. According to their study, biofilm formation is a
protective system under different environmental stress
conditions.146 Recent studies have demonstrated that bile
salts increase the capacity of S. flexneri strains to adhere to
and penetrate epithelial cells.147,148 Indeed, extended expo-
sure of Shigella to bile salts occurred in cases of increased
biofilm formation, and thus it is an important resistance
mechanism for Shigella sp. Similar biofilm phenotypes
have been observed for Campylobacter, Listeria, and
Vibrio, demonstrating that bile salt–induced biofilm produc-
tion is conserved among members of the Enterobacteriaceae
family.19,148 Also, biofilm formation has been shown to
require the presence of glucose, whereas biofilm diffusion
requires the elimination of bile salts from the medium.19
Bacteria in the form of biofilm can be 100,000 times more
resistant to antimicrobial agents than planktonic forms of
bacteria in the same species.143 During biofilm formation,
the effect of shf, mdoH, VpsT, and LuxR-like genes and OpgH
protein expression has been confirmed among enteric bac-
teria, as well as Shigella.143,145 Another study described
biofilm-formation potentials and pathological behaviors of
various mutants S. flexneri strains with an incomplete inner
core of LPS containing only Kdo moieties.
Interestingly, 1rfaC (also called waaC) mutant, with
an incomplete inner core of LPS due to deficiency in
Hep biosynthesis, shows strong biofilm-formation ability
and considerably high invasiveness and adhesiveness to
human epithelial cells compared LPS-mutant strains.
However, this strategy is successful in conferring high-
level resistance only in bacterial species with a defi-
ciency in Hep synthesis of LPS.149 The relationship
between biofilm formation and pathogenicity, as well
as virulence factors and antimicrobial properties, has
not been thoroughly studied in Shigella spp., and further
studies are needed.
Therapeutics
Treatment for Shigella infections is recommended to pre-
vent spread of infection to others and to shorten disease
duration. According to current WHO guidelines and a sys-
tematic review, the use of fluoroquinolones (first-line,
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preferably ciprofloxacin), cephalosporins (second-line), and
β-lactams (second-line) for 7–10 days is recommended for
treatment of shigellosis.4,111 In regions known to have high
rates of resistance to ciprofloxacin, azithromycin may be
considered appropriate second-line therapy. Cefixime is also
a good alternative, although its use should be balanced with
respect to risk of developing antimicrobial resistance and
spread of ESBL.111 Conventional antibiotic therapeutics
against shigellosis have become increasingly inefficient,
due to the increase in number of MDR strains. However,
no well-designed in vitro or in vivo combinations of anti-
microbial agents have been performed to evaluate different
antibiotic-class regimens for treating infections caused by
Shigella. There has only been a related study on an anti-
microbial-sensitivity case series reporting resistance in dif-
ferent regions and treatment outcomes for infections caused
by Shigella.4,111 In general, it has been observed that there
is a decrease in susceptibility to first- and second-line
agents. As such, there is an urgent need for development
of novel therapeutic strategies for treatment of MDR
Shigella infections.111
Alternative Therapeutics
Natural And Organic Products
Natural products are small molecules produced naturally
by microbial agents, plants, and animals that have been
demonstrated to be useful in treating Shigella infections.
Biotherapeutic agents (preferably probiotics) have been
suggested in prevention of antibiotic-induced diarrhea,
and are also an alternative therapeutic choice for treatment
of gastroenteritis infectious.150 Bacteria and yeast are the
most frequent microorganisms used as probiotics. Several
mechanisms have been suggested for antimicrobial activity
of bacteria toward enteric bacterial pathogens, including
production of undissociated organic acids, organic acid
molecules, and bacteriocin, competition for adhesion
sites, and coaggregation with pathogens.151
Pretreatment of cells with bacterial components and
products obtained from Lactobacillus rhamnosus and L.
acidophilus results in interference with Shigella adherence
and internalization into host cells and leads to an absence of
IL8 expression, substantiating attenuation of inflammatory
response during aggregate pretreatment. Lactobacilli have
been shown to regulate cytokine production and stimulate
the immune system.152 Time-kill methodology has shown
that viability of S. sonnei decreased after contact with cell-
free culture supernatants of lactobacilli, which could be
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potentially used as probiotic strains in food industry.151
Zhang et al selected a total of 91 lactobacilli for antimicro-
bial activity against Shigella isolates, among which 16
lactobacilli displayed potent antibacterial activity against
S. sonnei strains. The nature of these antimicrobial agents
was studied and found to be dependent on production of
organic acids.153 Also, other studies have indicated that
lactobacilli and lactic and acetic acid bacteria possess high
activity against MDR Shigella pathogenic strains, and that
they can be the best candidate for probiotics.152,154,155
Saccharomyces boulardii is a thermophilic and nonpatho-
genic yeast showing antagonistic activity against several
bacterial pathogens, such as enterohemorrhagic and enter-
opathogenic E. coli, Vibrio cholera, Salmonella typhimur-
ium, and S. flexneri.156
In one study, the effect of aqueous ethanol extract of
Euphorbia prostrata was investigated in vitro and in vivo
on bacterial growth of S. dysenteriae type 1 and found to
be effective against Shigella isolates, with MIC and mini-
mal bactericidal concentration of 3,500–12,000 µg/mL.157
The preventive role of orally administered Aloe barbaden-
sis Miller (Aloe vera)–supplemented probiotic lassi (APL)
was determined for S. dysenteriae infection in mice, with a
significant (P<0.05) decrease found in Shigella counts (log
CFU/mL) and immunoprotective effects of APL against S.
dysenteriae.158 Antivirulence activity of a boiling black tea
(Camellia sinensis) extract was shown to reduce expres-
sion of virulence traits by S. dysenteriae, as shown by
decreased bacterium-survival strategies, and also an
enhancement was found in innate immunoresponse against
Shigella isolates.159 Antishigellosis activity of Picralima
nitida Stapf (Apocynaceae) extract has been found to be
effective against S. dysenteriae type I strains, and MIC and
minimal bactericidal concentration were 800 and 6,400 μg/
mL, respectively.160 In vitro antibacterial activity of
methyl gallate isolated from Terminalia chebula has been
shown to cause total disintegration of outer and inner
membranes and leakage of cytoplasmic contents of MDR
S. dysenteriae. Viable intracellular S. dysenteriae reduced
in a time-dependent manner in the presence of methyl
gallate and decreased to zero within 20 hours.161 In
another study, antimicrobial activity of thyme oil and
ciprofloxacin and their synergistic effects were evaluated,
and the combination displayed differing degrees of effects
on microbial cell formation based on results obtained from
scanning electron microscopy and transmission electron
microscopy. In vitro and in vivo synergy between them
showed maximum growth inhibition in S. flexneri.
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Bacterial loads in infected colons reduced as a result of
treatment with thyme oil, while the conventional drug
failed to heal colon ulcers. Also, it decreased penetration
of lamina propria by inflammatory cells.162
Antishigellosis activity of a Crinum jagus water–etha-
nol extract was found to be effective against S. flexneri,
with inhibition of diameter by 18.90 (0.39 mg/mL) and
25.36 (200 mg/mL) mm, respectively. Indeed, Crinum
jagus extract drastically decreased (P<0.01) diarrheal
stool emission and microbial load and also reduced IFNγ,
IL2, IgM, IgA, and motilin blood levels in S. flexneri–
induced diarrheic rats.163 An in vitro study on bovine
lactoferrin recognized it as a coadministered adjuvant ther-
apeutic in antibiotic therapy against Shigella isolates.
Some strains of Shigella show a twofold or more decrease
in their ampicillin MIC values in the presence of bovine
lactoferrin.164 In vitro data showed that antibacterial activ-
ity of gallic acid inhibited the effect on biofilm formation
and reduced the number of viable S. flexneri strains.
Indeed, gallic acid inhibited biofilm formation in S. flex-
neri by regulating expression of the mdoH gene. mdoH is
essential for glucosyltransferase activity and osmoregu-
lated periplasmic glucans synthesis, as they both contri-
bute to biofilm formation and develop antibiotic resistance
in pathogenesis. Inhibition of mdoH can help in treatment
of S. flexneri biofilm.143 Organic acids, such as citric,
acetic, lactic, and malic acid, are natural substances cate-
gorized as “generally recognized as safe” according to the
US Food and Drug Administration. They have antimicro-
bial activity and are widely used to inactivate bacteria.
Results of a study showed that organic acids, carvacrol,
and their combination were useful against S. sonnei.
However, S. sonnei was shown to decrease to 4.53 and
3.25 log CFU/mL using 0.5% w:v malic, lactic acid,
respectively, indicating the synergistic effect of combina-
tion therapy.165 A previous study reported the effects of
dithiocarbamate transition-metal complexes on survival
and recovery of pathogenic bacteria, and they are very
attractive and novel pharmaceutical targets for control
and management of antibiotic-resistant bacteria, as well
as Shigella isolates.166
Novel Therapeutic Strategies For
Shigella Treatment
Nanoparticles
Nanoparticles (NPs) have gained growing importance in
recent years and shown broad-spectrum antibacterial
Infection and Drug Resistance 2019:12
Ranjbar and Farahani
activity against pathogenic bacteria, due to their bacterici-
dal characteristics.167 NPs usually destroy bacterial targets
with a damaging effect on membrane load cells and their
integrity, along with generation of free oxygen radicals.
Commonly, they can be delivered efficiently as antimicro-
bial agents. Recently, copper oxide NPs have been recog-
nized as an antimicrobial agent for treatment of Shigella.
MIC and minimum bactericidal concentration of copper
oxide NPs were 2,500 μg/mL and ≤5,000 IU/mL, respec-
tively, in treatment of S. sonnei using 33 nm NPs. The
study also showed that smaller copper oxide NPs had
stronger antibacterial effects than larger NPs at a specific
time and concentration.168 Iron is a biocompatible ele-
ment, and can be directly used for treatment of many
types of microbial pathogens. In one study, antimicrobial
properties of Fe2O3 and Ag–Fe2O3 NPs against S. dysen-
teriae strains was evaluated, and both Fe2O3 and Ag–
Fe2O3 NPs were shown to have antimicrobial effects,
with antimicrobial activity of Ag–Fe2O3 NPs much more
than that of Fe2O3 NPs alone.169 The bactericidal effect of
iron oxide NPs has been determined, with values of 50–
100 μg/mL against Gram-positive and Gram-negative bac-
teria, as well as S. dysenteriae and E. coli.167 The use of
nanoantibiotic formulations is another strategy for treat-
ment of drug-resistant Shigella. Mukherjee et al reported
on the synthesis of a nanosized form of tetracycline by
loading it in calcium phosphate NPs and showed that this
treatment significantly decreased incidence of colon-length
shortening, mushy-stool excretion, weight loss, and micro-
bial colonization in gastrointestinal tracts of Shigella-
infected mice. Immunohistological research has shown
that as a result of tetracycline–calcium phosphate NP
treatment, changes in morphology and level of inflamma-
tory cytokines IL1β, IFNγ, and TNFα in intestinal tissue of
mice caused by shigellosis were reverted to almost normal
characteristics.170 Silver NPs (AgNPs) are characterized
by their broad-spectrum bactericidal toxic effects against
broad-spectrum bacterial pathogens. Omara et al tested
AgNPs against pathogenic Salmonella and Shigella strains
recovered from layer-poultry farms. AgNPs at a concen-
tration of 16 μg/mL were found to have both bacteriostatic
and bactericidal effects against Salmonella and Shigella
isolates.171 Although NPs have shown high antibacterial
activity during in -vitro and in -vivo experiments, future
studies and judiciously performed clinical trials are
required to achieve a better understanding of their poten-
tial side effects and clear regulatory guidelines.
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Phage Therapy
Bacteriophages (phages) are the most abundant organisms
killing bacteria a through lysis mechanism. They can be recov-
ered from various environments. Phage therapy has earned
increasing attention due to several advantages, including high
specificity to target bacteria without effects on normal micro-
flora of the human body, replication at infection site, bacter-
icidal activity against antibiotic-resistant bacteria, and fewer
side effects than other therapies. Phages are self-limiting,
because phages remain at a shallow level on target sites after
killing bacterial targets.172 Phage therapy of shigellosis was
discovered by a French microbiologist named d'Herelle,
who described efficacy of phages in curing symptoms of
dysentery.173 Use of phages for treatment of MDR S. dysenter-
iae recovered from wastewater has been investigated as an
alternative to antibiotics.172 Another study showed that a viru-
lent phage named pSb1 was able to infect all the S. boydii
strains and had productive lytic activity against them. Also,
results indicated that pSb1 might be a member of an N4-like
phage group and might have potential applications as an alter-
native option for treatment of shigellosis.174 Regular targeting
of only a subgroup of strains within one bacterial species or
closely related species without causing distortions in the gut
microbiota is one of the benefits of phage treatment over
antibiotic therapy in treatment of shigellosis.175 Numerous
animal have studies demonstrated that phages are able to
survive in experimental animals with dysentery. Despite no
reports on significant undesirable reactions during the long
history of phage therapy in humans,176 phage treatments still
need to overcome admission constraints in the main medical
repertoire.
Vaccine Strategies
Varieties of candidate vaccines have been developed to pre-
vent infection by Shigella spp., most of which are currently
under evaluation for safety and immunogenicity. However,
there is no licensed vaccine available against this pathogen.
At present, studies in humans and animals have shown that
protection by vaccination is possible. Potential candidates for
Shigella vaccines include glycoconjugate vaccines, such as
recombinant glycoconjugate, synthetic glycoconjugate,
O-polysaccharide covalently linked to immunogenic carrier
proteins,177,178 virG-based live attenuated (WRSS1, WRSs3,
WRSf3, WRSf2G12, WRSf2G15and WRSd1),179,180
recombinant outer-membrane proteins,181 live attenuated
vaccines,182,183 invasion-plasmid antigens B, C, and D,184
DNA-based vaccines, Ty21a typhoid vaccine expressing
Shigella LPS,185 recombinant probiotic–based candidates,186
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and whole-cell-killed and Shigella trivalent inactivated
whole-cell and heat-killed multiserotype Shigella,187,188 as
well as novel antigen candidates, such as triacylated S-LPS,
subcellular complexes purified from virulent cultures
(Invaplex),189 GMMA protein particles,190 and an OMV-
NP vaccine (Table 3).191
Live attenuated strains such as S. dysenteriae type 1
WRSd1, S. sonnei WRSS1, WRSs2, WRSs3, and some
whole-cell-killed and novel antigen candidates are now devel-
oping, and were safe and immunogenic in a phase I trial (more
details are presented in Table 3). Among possible Shigella
candidate vaccines, GMMA protein particles, live attenuated
Shigella flexneri 2a SC602, and S. dysenteriae type 1 SC599
strains have entered phase II clinical evaluation, and only
glycoconjugate candidates have already undergone Phase III
trials, with other formulations still under development in
patients with shigellosis.192,193 As shown in Table 3, many
studies have demonstrated humoral response as a main value of
an immunoresponse to vaccination, and also fever and transi-
ent diarrhea have been repaorted as the most frequent compli-
cations in relation to some vaccine candidates in clinical
investigations (Table 3). Finally, it seems that development
and evaluation of multivalent candidates may provide a
means for protection against serogroups/serotypes of Shigella
in future.
Conclusion
In this review, antibiotic-resistance mechanisms and thera-
peutic strategies have been summarized regarding Shigella
infection. Antimicrobial resistance in Shigella spp. is multi-
factorial in that it can occur through innate, acquired, or
adaptive mechanisms, and infections resulting from it are
exceedingly difficult to treat. Drug resistance among
Shigella spp. occurs as a result of selective pressure and
horizontal resistance-gene transmission. Accordingly, there
is an urgent need to comprehensively learn and understand
mechanisms of drug resistance among Shigella isolates, in
order to develop antishigellosis drugs. The multifarious nat-
ure of antibiotic-resistance mechanisms contributes in an
increase in the number of MDR strains and causes conven-
tional antibiotic therapeutics to be highly inefficient against
shigellosis. Despite intensive research efforts in the last few
decades related to determination of antimicrobial resistance,
researchers have not been able to find the best solution to
control MDR isolates. Also, direct contributions to antibiotic
resistance by many antimicrobial-resistant mechanisms
remains unknown, showing a need for continuous monitor-
ing of a broader range of associated mechanisms contributing
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 Table 3 Overview Of Shigella Vaccines In A Aifferent Phase
Dovepress

Class/type Investigational Delivery Target Antigen (Type) Valued Status And Results Limitations Development Reference
Vaccines Systems Immunoresponse Phase

Live vaccine
198
Live-vaccine Escherichia albertii strain Intranasal Whole-cell E. albertii Humoral Completed, efficacy, protection in Unknown Preclinical
candidate strain DM104 guinea pigs

Infection and Drug Resistance 2019:12

Attenuated vaccines
176
Live attenuated S. flexneri 2a WRSf2G12, Ocular virG, set, senA, sbB2 genes Humoral Ongoing, protection in guinea pigs Needs balancing Preclinical
strains WRSf2G15 immunogenicity
with reactogenicity
199
S. dysenteriae type 1 Oral virG gene Humoral Efficacy when given orally Transient diarrhea Phase I
WRSd1
200
S. flexneri 2a (SC602) oral virG, iuc genes Humoral Completed, efficacy, protection ND Phas IIB
201
S. dysenteriae type 1 SC599 Oral virG, ent, fep, stxA genes Humoral Completed, efficacy, protection Unknown Phase II
177
S. sonnei WRSS1 Oral virG gene Humoral Phase I, ongoing, protection in adults Children elicited Phase I
lower mucosal
immunoresponses
than adults
176
S. sonnei WRSs2, WRSs3 Oral virG, senA, senB, msbB2 Humoral Ongoing, need for human challenge Fever, transient Phase I
genes models for the efficacy of the diarrhea
vaccine
179
Trivalent of S. flexneri Intranasal guaBA gene Humoral Ongoing, prevention in guinea pigs Unknown Preclinical
serotypes and needs further development
180
S. flexneri 2a CVD 1208S Oral guaBA, set, sen genes Humoral and Completed, efficacy, prevention and ND Phase II
cellular induces diverse T-CMI responses in
human volunteers
181
RNA-binding protein Ocular and hfq gene and ipaBCDA Humoral Ongoing, induced protective Animals vaccinated Preclinical
mutants of S. dysenteriae oral plasmid immunity in the eye showed
type 1 and S. sonnei fewer symptoms

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(Continued)

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 3158
Table 3 (Continued).

Class/type Investigational Delivery Target Antigen (Type) Valued Status And Results Limitations Development Reference
Vaccines Systems Immunoresponse Phase

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182
Hybrid and live Salmonella enterica serovar Oral O-antigen biosynthesis Humoral Completed, efficacy, protection in Unknown Preclinical
attenuated Typhi strain, Ty21a gene mice
vectors 202
S. flexneri 2a Intranasal and virG, aroA genes Humoral Ongoing, efficacy and future Fever and diarrhea Phase II
oral investigation need for more
attenuated recombinant mutant

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strains
203
Live transconjugant Shigella Oral stx gene Humoral and Completed, efficacy and good Unknown Preclinical
hybrid (LTSHΔstx) strain cellular protection in mice
204
Escherichia coli K12 Oral pWR110–R64drdll Humoral Stopped, causes mild diarrhea in Fever, mild diarrhea Preclinical
invasiveness plasmid human primates to frank dysentery
204
E. coli K12, EcSf2a-3, Oral virG, aroD genes Humoral Stopped, EcSf2a was immunogenic Not sufficiently Preclinical
EcSf2a-5 but also reactogenic and thus not attenuated
sufficiently attenuated in the guinea
pig

Inactivated vaccines
205
Whole cell– Shigella with a truncated Intranasal wzy gene Humoral Completed, efficacy, protection ND Preclinical
killed vaccines O-SP
206
S. flexneri 2a Oral Inactivated whole cells Humoral and Completed, safety, robust ND Phase I
cellular immunoresponse
205
S. sonnei Oral Inactivated whole cells Humoral Completed, efficacy, protection ND Phase I
184
Trivalent of Shigella whole Intranasal Formalin inactivation of S. Humoral Completed, efficacy, protection from Unknown Preclinical
cells flexneri 2a, S. sonnei, and S. lethality in guinea pig infection model
flexneri 3a
185
Heat-killed multiple Oral S. dysenteriae 1, S. flexneri Humoral and Completed, efficacy, protection in ND Preclinical
serogroups/serotypes of 2a, S. flexneri 3a, S. cellular rabbit infection model
Shigella (HKMS) flexneri 6, S. boydii 4 and
S. sonnei

(Continued)
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Infection and Drug Resistance 2019:12

 Table 3 (Continued).

Class/type Investigational Delivery Target Antigen (Type) Valued Status And Results Limitations Development Reference
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Vaccines Systems Immunoresponse Phase

178
Subunit vaccines IpaDB fusion proteins Intradermal Invasion plasmid antigens Humoral Ongoing, protective efficacy using a ND Preclinical
B and D (IpaB and IpaD) mouse pulmonary infection model
207
rIpaB domain rGroEL Lung S. flexneri IpaB, S. Typhi Humoral Immunogenic and protective efficacy ND Preclinical
GroEL against S. flexneri, S. boydii and S.
sonnei in BALB/c mouse infection
model

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208
Glycoconjugate Bioglycoconjugates Intramuscular S. dysenteriae 1 LPS Humoral Ongoing, protection, additional ND Phase I
candidates exoprotein A serotypes will be tested shortly
209
Lipid-linked S. dysenteriae– Intramuscular O-SP Ag Humoral Ongoing, need future studies using Low level of Preclinical
type 1 O-polysaccharide synthetic saccharides of different antibodies
size
174
O-polysaccharide Subcutaneous O-SP Ag Humoral Ongoing studies Unknown Preclinical
covalently linked to
immunogenic carrier
proteins
209
Synthetic oligosaccharides Intramuscular S. flexneri 2a O-SP Ag Humoral Ongoing, need future studies for the Unknown Preclinical
tetanus toxoid development of multivalent
glycoconjugate vaccines
186
Novel antigen Artificial Invaplex Intranasal LPS, IpaB, and IpaC Ag Humoral Efficacy, protection in mice, need ND Preclinical
candidates (recombinant IpaB and future testes for determination of
IpaC proteins with purified safety and immune response in
Shigella LPS) humans
108
Triacylated S-LPS Parenteral Partial alkaline Humoral Completed, efficacy, protection with Unknown Phase I
deacylation of S-LPS robust humoral immunoresponse
187
GMMA protein particles - Outer-membrane Humoral Completed, good safety and ND Phase IIa
particles from S. sonnei immunogenicity profiles in healthy
and S. flexneri 2a adults
210
ΔtolA-OMV vaccine Intramuscular Outer-membrane Humoral An ongoing, potentially cost- ND Preclinical
vesicles, disruption of tolA effective vaccine in the mouse

DovePress
submit your manuscript | www.dovepress.com
gene from S. boydii 4 infection model
188
OMV-nanoparticle vaccine Intranasal Shigella outer-membrane Humoral Ongoing, need future studies for the ND Preclinical

3159
Ranjbar and Farahani

vesicles development of a multivalent vaccine

(Continued)
Ranjbar and Farahani Dovepress

to development of MDR strains. Most candidate vaccines

Reference
cause an improvement in host immunity along with preven-
tion of infection, but some have low efficiency and host

183

183
challenge, which must be thoroughly overcome before

Development
being used against Shigella infection. More understanding
on the host–microbe relationship is needed to develop novel

Preclinical
Preclinical
Phase therapeutic strategies to fight shigellosis. Development of
innovative therapeutic and alternative strategies is also
required for prevention and treatment of Shigella infections.
Limitations

Unknown Author Contributions

Unknown

Both authors conceptualized and designed the review, con-

tributed towards data analysis, drafting and critically revising
the paper, gave final approval of the version to be published,
protection from Shigella needs to be
Ongoing, prevention in adult and

and agreed to be accountable for all aspects of the work.

Ongoing, efficacy of provoked
immunoresponses in affording

Disclosure
Status And Results

The authors report no conflicts of interest in this work.

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